Quantity Limits List

Taking too much medicine or using it too often isn’t safe. And it may even drive up your health care costs. That’s why this program limits the amount of medicine that’s covered by your plan for a certain length of time. For example, a drug may have a limit of 30 pills per 30 days. If you refill a prescription too soon or your doctor prescribes an amount that’s higher than usual, your pharmacist will tell you. The drug won’t be covered at that time.

Use this table to see if one of your has a quantity limit.

Find your type of drug in the columns on the left. Then look for the name of your drug. The amount that’s covered by your plan is listed in the right-hand column.

Category Type Quantity limit Health and High Cardene SR 2 capsules per day Blood Pressure Pressure Allergy Antihistamine Allegra 180mg 1 tablet per day Antihistamine Allegra 900ml 1 tablet per day Antihistamine/ Allegra 30mg, 60mg 2 tablets per day Antihistamine/ Allegra D 180mg/240mg 1 tablet per day Decongestant Antihistamine/ Allegra D 60mg/120mg 2 tablets per day Decongestant Nasal Antihistamine Astelin Nasal Spray 1 nasal per 25 days Nasal Antihistamine Astepro Nasal Spray 137mcg, 205.5mcg 1 nasal inhaler per 25 days Nasal Antihistamine Atrovent Nasal Spray .03% 2 bottles per 30 days Nasal Antihistamine Atrovent Nasal Spray .06% 2 bottles per 30 days Nasal Steroid Beconase AQ nasal inhaler 2 per 30 days Clarinex 1 tablet per day or 300ml per 30 days Clarinex D (12-hour tablet/capsule) 2 tablets per day Clarinex D (24-hour tablet/capsule) 1 tablet per day Flonase Nasal Spray 1 inhaler per 30 days Nasal Spray 25mL (3 inhalers) per 30 days Grastek 1 tablet per day Lastacaft 0.25% Eye Drops 2 per 30 days Nasacort AQ Nasal Spray 1 inhaler per 30 days Nasarel Nasal Spray 3 inhalers per 30 days Nasonex Nasal Spray 2 inhalers per 30 days Omnaris Nasal Spray 1 inhaler per 30 days Oralair 100 IR- 3 tablets per grass pollen season Patanase Nasal Spray 30.5g 1 nasal inhaler per 30 days Ragwitek 1 tablet per day Rhinocort Aqua Nasal Spray 2 inhalers per 30 days Veramyst Nasal Spray 1 inhaler per 30 days Xyzal 2.5mg/5ml 300ml per 30 days Xyzal 5mg 1 tablet per day

45231ANMENABS VPOD Rev. 07/15 Category Type Medication Quantity limit Allergy Zyrtec 5mg, 10mg (including chewables) 1 tablet per day Zyrtec-D 2 tablets per day Allergy/ Singulair 30 units per 30 days Anti-acne treatment Isotretinoin 30 days per fill Xifaxan 200mg 9 tablets/capsules per 30 Xifaxan 550mg 60 tablets/capsules per 30 days Eliquis 2 tablets per day Xarelto 42 tablets per 30 days Antiepileptic Diastat 2 syringes per fill; 5 fills per 30 days Anti-inflammatory Mobic (meloxicam) 7.5mg/ml suspension 300ml per 30 days (Nonsteroidal) Arrhythmias Cordarone 3 tablets per day Arthritis Orencia (125mg) 4 vials per 28 days Xeljanz 2 tablets per day Arthritis/ Cimzia 1 pack or kit = 2 x 200mg vials per 28 days Crohn's Disease 1 syringe kit = 2 x 200mg/ml syringes per 28 days” Arthritis/Crohn's Humira Pen — starter pack 40mg/0.8ml 1 pack (one-time fill) Disease/ Arthritis/Crohn's/ Humira 2 pens or syringes every 28 days Psoriasis Arthritis/Psoriasis Enbrel 2mg 8 vials every 28 days Enbrel 50mg 4 vials every 28 days Simponi 1 injection per 28 days Asthma Anti-Inflammatory Aerospan 2 inhalers per 30 days (Inhaled) Anti-Inflammatory Alvesco 160mcg 2 inhalers per 30 days (Inhaled) Anti-Inflammatory Alvesco 80mcg 1 inhaler per 30 days (Inhaled) Anti-Inflammatory Anoro Ellipta 1 inhaler (60 blisters) (Inhaled) Anti-Inflammatory Asmanex 1 inhaler per 30 days (Inhaled) Arnuity Ellipta 100 mcg/actuation, 200 mcg/ 1 inhaler per 30 days actuation Asmanex HFA 1 inhaler Dulera Inhaler 100 and 200mcg 1 inhaler per 30 days Flovent Diskus 4 inhalers per 30 days Flovent HFA 110 inhaler, 44 inhaler 1 inhaler (13gm) per 30 days Flovent HFA 220 inhaler 2 inhalers (13gm) per 30 days Incruse Ellipta 1 inhaler per 30 days Maxair Autohaler 2 inhalers per 30 days Pristiq 100mg 1 tablet per day ProAIR inhaler (27gm) 2 inhalers per 30 days Proventil HFA (21gm) 3 inhaler per 30 days Pulmicort Flexhaler 2 inhaler per 30 days Pulmicort respules 0.25mg/2ml 2 boxes per 30 days Pulmicort respules 0.5mg/2ml 2 boxes per 30 days Category Type Medication Quantity limit Asthma Pulmicort respules 1mg/2ml 1 box per 30 days QVAR inhaler 40mcg 1 inhaler 80mcg 2 inhalers Serevent Diskus 1 inhaler per 30 days Ventolin HFA inhaler 2 inhalers per 30 days Xopenex HFA 2 inhalers per 30 days Asthma/COPD Anti-Inflammatory Advair Diskus (60ml) 1 inhaler per 30 days (Inhaled)/ Bronchodilator Combination Anti-Inflammatory Advair HFA (12gm) 1 inhaler per 30 days (Inhaled)/ Bronchodilator Combination Foradil 2 capsules per day Symbicort 10.2gm 1 inhaler per 30 days Birth Control Plan B One-Step 1 tablet per 30 days Plan B/Next Choice 0.75mg 2 tablets/capsules per 30 days 1.5mg 1 tablet/capsule per 30 days” Blood Builder Neulasta 2 vials per 28 days Fracture/ Pain Xgeva 120mg 1 vial per 28 days due to Cancer Cancer Treatment Afinitor 10 mg 1 tablets per day Afinitor 2.5 mg 4 tablets per day Afinitor 5 mg 2 tablets per day Afinitor 7.5 mg 40 tablets per 30 days Afinitor Disperz 2 mg 2 tablets per day Afinitor Disperz 3 mg 3 tablets per day Afinitor Disperz 5 mg 2 tablets per day Arimidex 1 tablet per day Aromasin 25 mg 2 tablets per day Bosulif 100 mg 4 tablets per day Bosulif 500 mg 1 tablet per day Caprelsa 100 mg 3 tablets per day Caprelsa 300 mg 1 tablet per day Cometriq 100 mg daily-dose pack (4 blister 1 dose pack (56 capsules) per 28 days cards, 80 and 20 mg capsules) Cometriq 140 mg daily dose pack (4 blister 1 dose pack (112 capsules) per 28 days cards, 80 and 20 mg capsules) Cometriq 20 mg 2 capsules per day Cometriq 60 mg daily-dose pack (4 blister 1 dose pack (84 capsules) per 28 days cards, 20 mg capsules) Eligard 22.5 mg Inj 1 per 12 weeks Eligard 30 mg Inj 1 per 16 weeks Eligard 45 mg Inj 1 per 24 weeks Eligard 7.5 mg Inj 1 per 4 weeks Erivedge 1 capsule per day Fareston 60 mg 1 tablet per day Farydak 10 mg, 15 mg, 20 mg 1 capsule per day Category Type Medication Quantity limit Cancer Treatment Femara 1 tablet per day Gilotrif 1 tablet per day Gleevec 100 mg 8 tablets per day Gleevec 400 mg 2 tablets per day Ibrance 75 mg,100 mg, 125 mg 1 capsule per day Iclusig 15 mg 2 tablets per day Iclusig 45 mg 1 tablet per day Imbruvica 4 capsules per day Inlyta 1 mg 8 tablets per day Inlyta 5 mg 4 tablets per day Jakafi 10 mg 5 tablets per day Jakafi 15 mg 100 tablets per 30 days Jakafi 20 mg 75 tablets per 30 days Jakafi 25 mg 2 tablets per day Jakafi 5 mg 10 tablets per day Lenvima 10 mg 2 capsules per day Lenvima 10 mg daily dose pack 1 pack per 30 days (30 capsules) Lenvima 14 mg daily dose pack 1 pack per 30 days (60 capsules) Lenvima 20 mg daily dose pack 1 pack per 30 days (60 capsules) Lenvima 24 mg daily dose pack 1 pack per 30 days (90 capsules) Lenvima 4 mg 1 capsule per day Lupron Depot 3.75 mg Kit 1 per 4 weeks Lupron Depot 45 mg Inj 1 per 24 weeks Lupron Depot Ped 7.5 mg 1 per 4 weeks Lynparza 16 tablets per day Lysodren 500 mg 38 tablets per day Mekinist 0.5 mg 3 tablets per day Mekinist 2 mg 1 tablet per day Nexavar 4 tablets per day Nilandron 150 mg 1 tablet per day1 Pomalyst 1 mg 4 capsules per day Pomalyst 2 mg 2 capsules per day Pomalyst 3 mg, 4 mg 1 capsule per day Revlimid 1 capsule per day Revlimid 2.5 mg, 5 mg, 10 mg, 15 mg, 20 mg, 1 capsule per day2 25 mg Sprycel 20 mg, 50 mg, 70 mg, 80 mg, 100 mg, 1 tablet per day 140 mg Stivarga 40 mg 4 tablets per day Sutent 12.5 mg 3 capsules per day Sutent 25 mg, 50 mg 1 capsule per day Tafinlar 4 capsules per day Tarceva 100 mg, 150 mg 1 tablet per day Tarceva 25 mg 3 tablets per day Targretin 10 capsules per day Tasigna 4 capsules per day Category Type Medication Quantity limit Cancer Treatment Temodar 100 mg, 140 mg, 180 mg, 250 mg 2 capsules per day Temodar 20 mg 4 capsules per day Temodar 5 mg 3 capsules per day Thalomid 150 mg, 200 mg 2 capsules per day Thalomid 50 mg, 100 mg 1 capsule per day Trelstar 22.5 mg Inj 1 per 24 weeks Trelstar Depot 3.75 mg Inj 1 per 4 weeks Trelstar LA 11.25 mg Inj 1 per 12 weeks Tykerb 6 tablets per day Vidaza 100 mg/vial 14 vials per 28 days Votrient 4 tablets per day Xalkori 2 capsules per day Xeloda 150 mg 6 tablets per day Xeloda 500 mg 10 tablets per day Xtandi 4 capsules per day Zelboraf 8 tablets per day Zoladex 10.8 mg Implant 1 per 12 weeks Zoladex 3.6 mg Implant 1 per 4 weeks Zolinza 4 capsules per day Zydelig 100 mg, 150 mg 2 tablets per day Zykadia 5 capsules per day Zytiga 250 mg 4 tablets per day Chronic Actimmune 12 vials per 28 days Granulomatous Disease COPD Bronchodilator Arcapta 75mcg 1 capsule per day Bronchodilator Atrovent inhaler 3 inhalers per 30 days Bronchodilator Atrovent solution 2.5ml 150 unit dose vials per 30 days Breo Ellipta 1 inhaler per 30 days Brovana 2 vials (120ml) per day Combivent inhaler 3 inhalers per 30 days Daliresp 500mcg 1 tablet per day Perforomist 2 vials (120ml) per day Spiriva 1 inhaler per 30 days Spiriva Respimat 1 inhaler per 30 days Stiverdi Respimat 1 inhaler per 30 days Cryopyrin- Arcalyst 4 vials per 28 days Associated Periodic Syndrome Diabetes Avandamet 2/1,000mg, 4/500mg, 2 tablets per day 4/1,000mg Avandamet 2/500mg 4 tablets per day Avandaryl 4-1mg, 4-2mg 2 tablets per day Accu-Check Compact Strips 204 per 30 days ActoPlus Met 15/500mg, 15/850mg 3 tablets per day ActoPlus Met 30/1,000mg 1 tablet per day ActoPlus Met XR 15/1,000mg 2 tablets per day Category Type Medication Quantity limit Diabetes ActoPlus Met XR 30/1,000mg 1 tablet per day Actos 1 tablet per day Afrezza 180 cartridges (90x4 unit and 90x8 unit) 3 boxes Afrezza 60 cartridges (4 unit) 9 boxes Afrezza 8 units 9 cartridges per day Afrezza 90 cartridges (30x4 unit and 60x8 unit) 5 boxes Afrezza 90 cartridges (4 unit) 6 boxes Afrezza 90 cartridges (60x4 unit and 30x8 unit) 6 boxes Afrezza 90 cartridges (8 unit) 4 boxes Avandamet 2-1000MG, 4-1000MG, 4-500MG 2 tablets per day Avandaryl 4-4mg 1 tablet per day Avandia 2mg, 4mg 2 tablets per day Avandia 8mg 1 tablet per day Blood Glucose Testing Strips, all brands 200 per 30 days Bydureon 4 vials per 28 days Bydureon Pen 4 prefilled pens per 28 days Byetta 1 prefilled pen per 30 days Diabetic Test strips 200 per 30 days Duetact 1 tablet per day Glyxambi 10 mg/5 mg, 25 mg/5 mg* 1 tablet per day Invokamet 2 per day Invokana 1 tablet per day Janumet 2 tablets per day Janumet XR 100mg-1,000mg 1 tablet per day Janumet XR 50mg-1,000mg 2 tablets per day Janumet XR 50mg-500mg 1 tablet per day Januvia 1 tablet per day Jardiance 1 per day Jentadueto 2 tablets per day Juvisync 1 tablet per day Kazano 12.5-1,000mg, 12.5-500mg 2 tablets per day Kombiglyze 1,000mg-2.5mg 2 tablets per day Kombiglyze 1,000mg-5mg 1 tablet per day Kombiglyze 500mg-5mg 1 tablet per day Nesina 12.5mg, 25mg, 6.25mg 1 tablet per day Onglyza 2.5mg, 5mg 1 tablet per day Oseni 12.5-15mg, 12.5-30mg, 12.5-45mg, 1 tablet per day 25-15mg, 25-30mg, 25-45mg Tanzeum 4 pens per 28 days Tradjenta 5mg 1 tablet per day Trulicity 4 prefilled pens/syringes per 28 days Victoza 1 box per 30 days Xigduo XR 5 mg/1000 mg 2 tablets per day Xigduo XR 5 mg/500 mg, 10 mg/500 mg, 10 1 tablet per day mg/1000 mg Excessive sleepiness Hetlioz 1 capsule per day Category Type Medication Quantity limit Excessive Nuvigil 150mg, 250mg 1 tablet per day Sleepiness Nuvigil 50mg 2 tablets per day Provigil 1 tablet per day Eye Drops Allergy eye drops Alamast 1 bottle per 30 days Allergy eye drops Alocril 1 bottle per 30 days Allergy eye drops Alomide 1 bottle per 30 days Allergy eye drops Bepreve 1 bottle per 30 days Crolom 1 bottle per 30 days Cromolyn sodium 1 bottle per 30 days Durezol 10ml per 30 days (2 x 5ml bottles or 4 x 2.5ml bottles) Elestat 1 bottle per 30 days Emadine 1 bottle per 30 days Lastacaft 2 per 30 days Optivar 1 bottle per 30 days Pataday 1 bottle per 30 days Patanol 1 bottle per 30 days Zaditor 1 bottle per 30 days Gastrointestinal Nausea/ Vomiting Anzemet 50mg 5 tablets per 30 days Health Nausea/ Vomiting Anzemet 100mg 5 tablets per 30 days Akynzeo 5 capsules per 30 days Emend 125mg 5 capsules per 30 days Emend 40mg 1 capsule per fill Emend 80mg 10 capsules per 30 days Emend Therapy Pack (3 capsules each) 5 packs (15 capsules) per 30 days Granisol solution 50 mL per 30 days Kytril 10 tablets/capsules per 30 days Ondansetron 24mg tablets 8 tablets per 30 days Sancuso 4 patches per 28 days Zofran Suspension 240ml per 30 days Zofran, ODT tablets/capsules 4mg 48 tablets per 30 days Zofran, ODT tablets/capsules 8mg 24 tablets/capsules per 30 days Zuplenz 4mg Soluble Film 48 per 30 days Zuplenz 8mg Soluble Film 24 per 30 days Gout Colcrys 69 tablets per 30 days Mitigare 2 capsules per day Heart Attack and Brilinta 90mg 2 tablets per day Stroke Prevention Plavix 75mg 1 tablet per day Zontivity 1 tablet per day Heart Attack Effient 10mg 1 tablet per day Prevention Heart Failure Corlanor 5 mg, 7.5 mg 2 tablets per day Category Type Medication Quantity limit Heart Health and Heart Failure Atacand 16mg 2 tablets per day Blood Pressure Treatment/High Blood Pressure Heart Failure Atacand 32mg 1 tablet per day Treatment/High Blood Pressure High Blood Atacand HCT 16/12.5mg 2 tablets per day Pressure High Blood Atacand HCT 32/12.5mg 1 tablet per day Pressure High Blood Avalide 150/12.5mg 1 tablet per day Pressure High Blood Avalide 300/12.5mg 1 tablet per day Pressure High Blood Avapro 300mg 1 tablet per day Pressure High Blood Azor 5/40mg, 10/40mg, 10/20mg 1 tablet per day Pressure High Blood Benicar HCT 40/12.5mg, 40/25mg 1 tablet per day Pressure High Blood Benicar 40mg 1 tablet per day Pressure High Blood Benicar 5mg 2 tablets per day Pressure High Blood Atacand 4mg, 8mg 2 tablets per day Pressure/Heart Failure Cardene SR 30mg, 45mg, 60mg 2 capsules per day Cardizem CD 300mg, 360mg 1 capsule per day Cardizem LA 300mg, 360mg, 420mg 1 tablet per day Covera-HS 180mg, 240mg 1 tablet per day Cozaar 100mg 1 tablet per day Cozaar 25mg 1 tablet per day Cozaar 50mg 2 tablets/capsules per day Diltiazem extended-release 12-hour 60 mg 2 capsules per day Diltiazem extended-release 12-hour 90 mg, 3 capsules per day 120 mg Diltiazem extended-release 240 mg, 300 mg, 1 tablet/capsule per day 360 mg, 420 mg Diltiazem hydrochloride 120 mg 3 tablets per day Diltiazem hydrochloride 30 mg, 60 mg, 90 mg 4 tablets per day Diovan 160mg 2 tablets per day Diovan 320mg 1 tablet per day Diovan 40mg, 80mg 3 tablets per day Diovan HCT 160/25mg, 320/12.5mg and 1 tablet per day 320/25mg Dynacirc CR 10mg 1 tablet per day Edarbi 80mg 1 tablet per day Edarbyclor 1 tablet per day Exforge 5/320mg, 10/160mg, 10/320mg 1 tablet per day Category Type Medication Quantity limit Heart Health and Exforge HCT 5/160/25mg, 1 tablet per day Blood Pressure 10/160/12.5mg, 10/160/25mg, 10/320/25mg

Hyzaar 100/12.5mg 1 tablet per day Hyzaar 100/25mg 1 tablet per day Isradipine 2.5mg 2 capsules per day Isradipine 5mg 4 capsules per day Micardis 80mg 2 tablets/capsules per day Micardis HCT 80/12.5mg 2 tablets/capsules per day Micardis HCT 80/25mg 1 tablet per day Nicardipine hydrochloride 20 mg 6 capsules per day Nicardipine hydrochloride 30 mg 3 capsules per day Nifedipine 10 mg, 20 mg 4 capsules per day Nimodipine 30 mg 12 capsules per day Norvasc 10 mg 1 tablet per day* Plendil 10 mg 1 tablet per day Sular 25.5 mg, 30 mg, 34 mg, 40 mg 1 tablet per day Tekamlo 150-10mg, 300-10mg, and 300-5mg 1 tablet per day Tekturna 30mg 1 tablet per day Tekturna HCT 150/25mg, 300/12.5mg, 1 tablet per day 300/25mg Teveten 400mg 2 tablets per day Teveten 600mg 1 tablet per day Teveten HCT 600/12.5mg, 600/25mg 1 tablet per day Tiazac 120mg, 180mg, 240mg, 300mg, 1 capsule per day Twynsta 40/10mg, 80/5mg, 80/10mg 1 tablet per day Valturna 300/320mg 1 tablet per day Verapamil ER 120 mg, 180 mg, 200 mg, 240 mg 2 tablets/capsules per day Verapamil ER 300 mg 1 tablet/capsule per day Verapamil hydrochloride 40 mg 3 tablets per day Verapamil hydrochloride 80 mg, 120 mg 4 tablets per day Verapamil SR 120 mg, 180 mg, 240 mg 2 tablets/capsules per day Verelan 240 mg 2 capsules per day Verelan 360 mg 1 capsule per day Hepatitis Harvoni 1 tablet per day Olysio 1 capsule per day Pegasys 4 vials per 28 days; 1 kit per 28 days Sovaldi 1 tablet per day Viekira Pak 1 pak per 28 days Hereditary Cinryze 20 vials per 30 days Angioedema High Cholesterol Advicor 1,000-20mg, 750-20mg 2 tablets per day Advicor 1,000-40mg 1 tablet per day Altoprev 60mg 1 tablet per day Caduet 5-80mg, 10-10mg, 10-20mg, 10-40mg, 1 tablet per day 10-80mg Category Type Medication Quantity limit High Cholesterol Crestor 40mg 1 tablet per day Lescol XL 80mg 1 tablet per day Lipitor 80mg 1 tablet per day Liptruzet 1 tablet per day Livalo 4mg only 1 tablet per day Niaspan 500mg 1 tablet per day Niaspan 750mg & 1000mg 2 tablets per day Pravachol 80mg 1 tablet per day Simcor 2 tablets per day Vytorin 1 tablet per day Zetia 1 tablet per day Zocor 80mg 1 tablet per day Hormonal Therapy Axiron 1 bottle per 30 days Fortesta 1 bottle per 30 days Testim 30 tubes per 30 days Topical Androderm 2.5mg 60 patches per 30 days Testosterone Topical Androderm 2mg/24hr Patch 30 patches per 30 days Testosterone Topical Androderm 4mg/24hr Patch 30 patches per 30 days Testosterone Topical Androderm 5mg 30 patches per 30 days Testosterone Topical AndroGel 1.62% 1.25 g and 2.5 g 1 packet per day Testosterone Topical AndroGel 2.5gm 60 packets per 30 days 2 units of the pumps per 30 Testosterone days Topical AndroGel 5gm 30 packets per 30 days 2 units of the pumps per 30 Testosterone days Natesto 3 pump bottles per 30 days Osphena 1 tablet per day Striant 2 tablets per day Testosterone 1% gel (12.5mg/1.25g) pump 2 pump bottles per 30 days Testosterone gel 50mg/5g packet 1 packet per day Testosterone gel 50mg/5g tube 1 tube per day Testosterone gel pump (10 mg per actuation) 1 pump bottle per 30 days 120 pumps/btl Vogelxo 12.5 MG/1.25 GRAM PUMP 2 pump bottles per 30 days Vogelxo 50 MG/5 GRAM GEL 1 tube per day Vogelxo 50 MG/5 GRAM GEL PACKT 1 packet per day Human Growth Egrifta (tesamorelin) (60 x 1mg vials) 1 box per 30 days Hormone Hyperammonemia Ravicti 525ml per 30 days Agent Indigestion, GERD, Indigestion ,GERD, Aciphex 1 tablet per day Peptic Ulcers peptic ulcers Indigestion ,GERD, Aciphex sprinkle 1 capsule per day peptic ulcers Dexilant 1 capsule per day Category Type Medication Quantity limit Indigestion, GERD, Esomeprazole 1 capsule per day Peptic Ulcers Nexium 1 capsule per day Prevacid 1 capsule per day Prilosec 20mg, 40mg 1 capsule per day Prilosec Powder packets for suspension 30 packets per 30 days Protonix 1 capsule per day Zegerid 30 packets per 30 days prevention Antibiotic Avelox 21 tablets per fill; 1 fill per 30 days and treatment Antibiotic Avelox ABC Pak 5 tablets (1 pack) per fill; 1 fill per 30 days Antibiotic Cipro 56 tablets per fill Antibiotic Cipro (ciprofloxacin) immediate‐release 28 tablets per fill; 1 fill per 30 days Antibiotic Cipro 10% (10 gm/100 mL) 4 bottles per fill; 1 fill per 30 days Antibiotic Cipro 5% (5 gm/100 mL) 7 bottles per fill; 1 fill per 30 days Antibiotic Cipro XR (ciprofloxacin) 1000 mg tablet 1 fill per 30 days Antibiotic Cipro XR (ciprofloxacin) 500 mg tablet 1 fill per 30 days Antibiotic Cipro XR 1,000mg 14 tablets per fill Antibiotic Cipro XR 500mg 3 tablets per fill Antibiotic Levaquin 14 tablets per fill; 1 fill per 30 days Antibiotic Levaquin (levofloxacin) 25 mg/1 mL (480 mL 280 mL per fill; 1 fill per 30 days bottle) Antibiotic Zithromax (azithromycin) 1g powder packets 2 packets per fill; 1 fill per 30 days Antibiotic Zithromax (azithromycin) 600 mg tablets 8 tablets per fill; 1 fill per 30 days Antibiotic Zithromax (azithromycin) suspension 100 15 mL per fill; 1 fill per 30 days mg/5 mL (15 mL bottle) Antibiotic Zithromax (azithromycin) suspension 200 67.5 mL per fill; 1 fill per 30 days mg/5 mL (22.5 mL bottle) Antibiotic Zithromax (azithromycin) suspension 200 60 mL per fill; 1 fill per 30 days mg/5 mL (30 mL bottle Antibiotic Zithromax (azithromycin) suspension 200 15 mL per fill; 1 fill per 30 days mg/5 mL(15 mL bottle Antibiotic Zithromax (azithromycin) tablets and Tri‐Pak 3 tablets per fill; 1 fill per 30 days 500 mg Antibiotic Zithromax (azithromycin) tablets and Z‐Pak 6 tablets per fill; 1 fill per 30 days 250 mg Antibiotic Zithromax 250mg 6 tablets/capsules per fill, 5 day therapy Antibiotic Zithromax 500mg 3 tablets/capsules per fill Antibiotic Zithromax 600mg 8 tablets/capsules per 30 days Antibiotic Zithromax Susp 15ml per fill 100mg/5ml suspension 15ml per fill (15ml size), 46ml per fill (23ml size), 60ml per fill (30ml size) 200mg/5ml suspension 2 packets per fill 1 gram powder Antibiotic Zmax 1 packet per fill Antibiotic Zmax (azithromycin ER) oral suspension 2 g/ 1 bottle (60 mL) per fill; 1 fill per 30 days bottle Antibiotic Zyvox 28 tablets/capsules per fill Antibiotic Zyvox Suspension 900ml per fill Factive 7 tablets per fill; 1 fill per 30 days Floxin 28 tablets per fill; 1 fill per 30 days Category Type Medication Quantity limit Infection prevention Influenza virus 2 fills per 180 days and treatment Noroxin 42 tablets per fill; 1 fill per 30 days Qualaquin 42 capsules per 365 days Relenza Diskhaler 1 pkg (20 ea) per dispensing (Age 7 and older. No mail service for this drug.) Sivextro 6 tablets per fill Tamiflu (oseltamivir) capsule 45mg 10 per fill Tamiflu (oseltamivir) capsule 75mg 10 per fill Tamiflu (oseltamivir) capsules 30mg 20 per fill Tamiflu Suspension 180 mL per fill Viread 150 mg, 200 mg, 250 mg, 300 mg 1 tablet per day Viread 40 mg/1 gm 8 gm per day four 60 g bottles for 30 days Zovirax Cream 5 grams per fill; 1 fill per 30 days Mental Health Aplenzin 1 tablet per day Brintellix 20mg 1 tablet per day Celexa (citalopram) 10mg/5ml 600ml/30 days Celexa (citalopram) 40mg tabs 1 tablet per day Celexa Suspension 600ml per 30 days Cymbalta 20mg, 60mg 2 capsules per day Daytrana 30 patches per 30 days Desvenlafaxine ER 100mg 1 tablet per day Effexor XR 150mg 1 capsule per day Fetzima 1 capsule per day Fluoxetine (Prozac) 20mg/5ml 600ml per 30 days Fluoxetine (Prozac) 40mg 2 capsules per day Fluoxetine HCL 60mg tablet 1 tablet per day Fluvoxamine 2 capsules per day Forfivo XL 450mg 1 tablet per day Khedezla 1 tablet per day Lexapro 20mg 1 tablet per day Lexapro 5mg/5ml Soln 600ml per 30 days Luvox CR (fluvoxamine) 100mg, 150mg 2 capsules per day Mevacor 40mg 2 tablets per day Paxil 1.5 tablets per day Paxil CR 25mg, 37.5mg 2 tablets per day Paxil Suspension 30 mL per day Pexeva 2 tablets per day Prozac weekly 90mg 4 capsules per 30 days Venlafaxine Extended Release tablets/ 1 tablet/capsule per day capsules 150mg, 225mg Venlafaxine immediate-release 25 mg, 37.5 mg, 3 tablets per day 50 mg, 75 mg, 100 mg Viibryd (vilazodone) 40 mg* 1 tablet per day Viibryd (vilazodone) titration pack 1 pack per year Wellbutrin 100 mg* 4.5 tablets per day Category Type Medication Quantity limit Mental Health Wellbutrin XL 300mg 1 tablet per day Zoloft 100mg 2 tablets per day Zoloft 20mg/ml 300ml per 30 days Migraine Medication Sumavel DosePro 4 syringes per 30 days Miscellaneous Esbriet 9 capsules per day Respiratory Ofev 2 capsules per day Multiple Sclerosis Ampyra 2 tablets per day Aubagio 1 tablet per day Gilenya 1 capsule per day Tecfidera 120mg one fill limit of 14 capsules 240mg 60 capsules per 30 days Nausea/ Vomiting Diclegis 4 tablets per day Omega 3 Fatty Acid Epanova 4 capsules per day Lovaza 4 capsules per day Vascepa 4 capsules per day Opioid Dependence Evzio 2 auto‐injectors per 30 days Suboxone Initial 3 months: 24mg/6mg per day Maintenance: 16mg/4mg per day Subutex 2mg 12 tablets/capsules per 90 days Subutex 8mg 8 tablets/capsules per 90 days Zubsolv Initial 3 months: 17.1mg/4.2mg per day Maintenance: 11.4mg/2.8mg per day Osteoporosis Actonel 150mg 1 tablet per day Actonel 35mg 4 tablets per 28 days Actonel 5mg, 30mg 1 tablet per day Atelvia 4 tablets per 28 days Binosto 4 tablets per 28 days Boniva 2.5mg 1 tablet per day Boniva 150mg 1 tablet per 28 days Fosamax 300ml per 30 days 70mg/75ml Fosamax 35mg, 70mg 4 tablets per 28 days Fosamax 5mg, 10mg, 40mg 1 tablet per day Fosamax Plus D 4 tablets per 28 days Miacalcin Nasal Spray 3.7ml 1 bottle per 30 days Prolia (16mg) 2 injections per year Forteo 1 pen per 28 days Pain Relief Migraine Amerge* This includes all drugs in this class 9 tablets per 30 days Migraine Axert* This includes all drugs in this class 9 tablets per 30 days Narcotic Actiq 120 units per 30 days Narcotic Analgesic APAP/Caf/Dihydrocodeine (Panlor DC) 11 capsules per day Narcotic Analgesic APAP/Caf/Dihydrocodeine 5 tablets per day (Panlor SS, Zerlor) Narcotic Analgesic APAP/codeine (Vopac 650-300) 6 tablets per day Narcotic Analgesic APAP/codeine (Tylenol with Codeine) 13 tablets per day Narcotic Analgesic APAP/codeine Susp or Elixir 1,200ml per 30 days (Capital with Codeine)” Category Type Medication Quantity limit Pain Relief Narcotic Analgesic Avinza 120mg 6 capsules per day Narcotic Analgesic Avinza 30mg, 60mg, 90mg 4 capsules per 30 days Transmucosal Abstral 6 sublingual tablets per day Immediate-Release Fentanyl Butalbital/APAP/Caffeine/Codeine 6 tablets/capsules per day (Fioricet with Codeine) Cambia 9 packets per 30 days Celebrex 100mg, 200mg 2 capsules per day Celebrex 400mg 1 capsule per day Combunox 4 tablets/capsules/day AND 28 tablets/ capsules/fill Duexis 3 tablets per day Duragesic 12.5mg, 25mg, 50mg 15 units per 30 days Duragesic 75mg, 100mg 30 units per 30 days Embeda 2 capsules per day Fentany (Actiq) 2 tablets per day Fentanyl (Duragesic 12mcg/hr, 15 units per 30 days 25mcg/hr, 50mcg/hr) Fentanyl (Duragesic 75mcg/hr, 100mcg/hr) 15 units per 30 days Fentanyl (Fentora) 120 units per 30 days Frova* This includes all drugs in this class 9 tablets per 30 days Hydrocodone/APAP (Hycet) 3,600ml per 30 days Hydrocodone/APAP (Lortab) 1,200ml per 30 days Hydrocodone/APAP (Maxidone, Vicodin ES) 5 tablets per day Hydrocodone/APAP (Norco) 12 tablets per day Hydrocodone/APAP (Zamicet) 2,700ml per 30 days Hydrocodone/APAP (Lorcet HD, Lortab, 8 tablets per day Vicodin) Hydrocodone/APAP 6 tablets per day (Lorcet, Lorcet Plus, Vicodin HP) Hydrocodone/APAP 13 tablets per day (Xodol 10-300, 5-300, 7.5-300) Hydrocodone/APAP 10 tablets per day (Zydone 10-400, 7.5-400, 5-400) Hydrocodone/Ibuprofen 16 tablets per day (Reprexain, Vicoprofen) Hysignla 2 tablets per day Imitrex injection 4 injections per 30 days Imitrex nasal inhaler 6 nasal inhalers per 30 days Imitrex* This includes all drugs in this class 9 tablets per 30 days Kadian 100mg, 200mg, 130mg, 150mg 6 capsules per day Kadian 10mg, 20mg, 30mg, 40mg, 50mg, 2 capsules per day 60mg,70mg 80mg Magnacet 10 tablets per day Maxalt* This includes all drugs in this class 9 tablets per 30 days Category Type Medication Quantity limit Pain Relief Maxalt-MLT* This includes all drugs in this 9 tablets per 30 days class Migranal nasal inhaler 1 kit = 8 canisters per 30 days Mobic 1 tablet per day Morphine sulfate (Avinza 30mg, 45mg, 60mg) 1 capsule per day Morphine sulfate (Avinza 75mg, 90mg, 120mg) 2 capsules per day Morphine sulfate (Kadian 10mg, 20mg, 30mg, 2 capsules per day 50mg, 60mg) Morphine sulfate (MS Contin 200mg) 2 tablets per day Morphine sulfate (MS Contin, Oramorph SR 3 tablets per day 15mg, 30mg, 60mg, 100mg) Morphine sulfate (Roxanol) 300ml per 30 days Nucynta 100mg 181 tablets/capsules per 30 days Nucynta 50mg, 75mg 362 tablets per 30 days Nucynta 75mg 242 tablets per 30 days Nucynta ER 2 tablets per day Onsolis 120 tablets/capsules per 30 days Opana ER 7.5mg, 10mg, 15mg, 20mg, 30mg 120 per 30 days Opana ER 40mg 6 tablets per day Oxycodone ER 10mg, 15mg, 20mg, 2 tablets per day 30mg, 40mg Oxycodone ER 60mg, 80mg 6 tablets per day Oxycodone/IBU (Combunox) 4 tablets/capsules/day AND 28 tablets/ capsules/fill Oxymorphone (Opana ER <40mg) 6 tablets per day Oxymorphone (Opana ER 40mg) 2 tablets per day Percocet 10/325 12 tablets per day Percocet 10/600mg 6 tablets per day Percocet 2.5/325 12 tablets per day Percocet 5/325 12 tablets per day Percocet 7.5/325 12 tablets per day Percocet 7.5/500 8 tablets per day Primlev 400 tablets per 30 days Relpax* This includes all drugs in this class 9 tablets per 30 days Roxicet 5/325 tablets 12 tablets per day Roxicet 5/500 8 capsules per day Roxicet solution 1800 mL per 30 days Rybix ODT 50mg tablet 8 tablets per day Savella 60 tablets/capsules per 30 days, 1 titration pack per year Stadol nasal spray 2 bottle per 30 days Targiniq ER 2 tablets per day Tivorbex 3 capsules per day Toradol 20 tablets/capsules per 30 days Toradol injections 60mg/30 days Tramadol (Ultram) 8 tablets per day Tramadol ER (Ryzolt, Ultram ER) 1 tablet/capsule per day Category Type Medication Quantity limit Pain Relief Tramadol/APAP (Ultracet) 300 per 30 days Treximet* This includes all drugs in this class 9 tablets per 30 days Trezix 10 capsules per day Tylox 8 capsules per day Vimovo 2 tablets per day Xartemis XR 7.5-325mg 4 tablets per day Xolox 240 tablets per 30 days Zecuity 4 patches Zohydro ER 10mg, 15mg, 20mg — 2 capsules per day 30mg, 40mg, 50mg — 4 capsules per day Zomig nasal spray 6 inhaler per 30 days Zomig* This includes all drugs in this class 9 tablets per 30 days Zorvolex 18mg, 35mg 3 tablets per day Parkinson's Disease Neupro 30 patches per 30 days Psoriasis Stelara 1 vial/syringe (45mg/0.5ml or 90mg/1ml) per 84 days (12 weeks). 1 additional vial/syringe (45mg/0.5ml or 90mg/1ml) one time only for the first 84 days (12 weeks) for initial dosing Seizures Diastat Rectal Gel 2 syringes per fill; 5 fills per 30 days Seizures/ Lyrica 25mg, 50mg, 100mg, 150mg, 200mg of Fibromyalgia/Nerve 90 caps per 30 days, 75mg, 225mg, 300mg limit of Pain 60 caps per 30 days Oral solution 20mg/ml limit of 900ml per 30 days Skin Condition Actinic Keratosis Aldara 12 packets per 28 days Entyvio 1 vial per 56 days Otezla 30mg 2 tablets per day Otezla Starter Pack 1 pack (14 day supply, one time fill) Picato 0.015% gel 1 carton per 90 days 0.05% gel 1 carton per 90 days Solaraze 1 dose per day Zyclara 14 packets per 28 days Zyclara 3.75% Cream Pump 1 pump bottle per 28 days Sleep Aid Insomnia Ambien 1 tablet per day Insomnia Ambien CR 1 tablet per day Belsomra 1 tablet per day Edluar 1 tablet per day Intermezzo 1 tablet per day Lunesta 1 tablet per day Rozerem 1 tablet per day Silenor 1 tablet per day Sonata 1 capsule per day Xyrem 18mL per day Zolpimist 1 bottle (60 sprays) per 30 days Smoking Cessation Buproban 2 tablets per day Bupropion 2 tablets per day Chantix 2 tablets per day and one starter pack per year Zyban 2 tablets per day Category Type Medication Quantity limit Stroke Prevention Aggrenox 2 capsules per day Pradaxa 60 capsules per 30 days

* Due to varying health benefi t plans, inclusion of a drug and related items on the Drug List is not a guarantee of coverage. Please refer to the prescription drug benefi t description of coverage, limitations and exclusions. This list may change during the year. If you have any questions, call Customer Service at the phone number listed on your member ID card.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Georgia: Blue Cross and Blue Shield of Georgia, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affi liates administer non-HMO benefi ts underwritten by HALIC and HMO benefi ts underwritten by HMO Missouri, Inc. RIT and certain affi liates only provide administrative services for self-funded plans and do not underwrite benefi ts. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.